Provider Demographics
NPI:1366812943
Name:PB MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PB MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:561-255-4135
Mailing Address - Street 1:2290 10TH AVE N STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2290 10TH AVE N STE 201
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6609
Practice Address - Country:US
Practice Address - Phone:561-225-2890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty